diff --git a/public/js/peGuide.js b/public/js/peGuide.js
index 237f7aa..94100a7 100644
--- a/public/js/peGuide.js
+++ b/public/js/peGuide.js
@@ -112,15 +112,104 @@
['6–11', 'Severe — admit, continuous monitoring'],
['≥ 12', 'Impending respiratory failure — ICU / airway management']
]
+ },
+ murmurGrade: {
+ title: 'Heart-murmur grading (Levine 1–6)',
+ icon: 'fa-wave-square',
+ rows: [
+ ['1/6', 'Very faint — heard only with concentration'],
+ ['2/6', 'Soft but readily heard'],
+ ['3/6', 'Moderately loud, no thrill'],
+ ['4/6', 'Loud WITH a palpable thrill'],
+ ['5/6', 'Very loud; audible with stethoscope just off the chest'],
+ ['6/6', 'Audible without the stethoscope touching the chest']
+ ]
+ },
+ pulseAmp: {
+ title: 'Pulse amplitude grade (0–4)',
+ icon: 'fa-heart-pulse',
+ rows: [
+ ['0', 'Absent'],
+ ['1+', 'Diminished, thready'],
+ ['2+', 'Normal'],
+ ['3+', 'Bounding'],
+ ['4+', 'Bounding with visible pulsation (e.g., aortic regurgitation)']
+ ]
+ },
+ capRefill: {
+ title: 'Capillary refill time',
+ icon: 'fa-hand',
+ rows: [
+ ['< 2 sec', 'Normal'],
+ ['2–3 sec', 'Borderline — consider hydration / perfusion'],
+ ['≥ 3 sec', 'Delayed — dehydration, shock, low cardiac output']
+ ]
}
};
// Which scales are relevant per system
var SYSTEM_SCALES = {
msk: ['atr', 'beighton'],
neuro: ['mrc', 'dtr', 'plantar'],
- resp: ['rr', 'spo2', 'silverman', 'westley']
+ resp: ['rr', 'spo2', 'silverman', 'westley'],
+ cv: ['murmurGrade', 'pulseAmp', 'capRefill']
};
+ // ────────────────────────────────────────────────────────────
+ // APTM DIAGRAM — the 5 classic auscultation points
+ // ────────────────────────────────────────────────────────────
+ // Inline SVG showing: Aortic, Pulmonic, Erb's, Tricuspid, Mitral.
+ // Rendered at the top of the cardiovascular system view.
+ // Patient faces viewer — viewer's LEFT = patient's right.
+ var APTM_SVG =
+ '
';
+
+ var APTM_LEGEND = [
+ { letter: 'A', color: '#dc2626', title: 'Aortic area', location: '2nd ICS, right sternal border', listen: 'S2 (aortic component), aortic stenosis, aortic regurgitation' },
+ { letter: 'P', color: '#2563eb', title: 'Pulmonic area', location: '2nd ICS, left sternal border', listen: 'S2 (pulmonic component), pulmonic stenosis, PDA, physiologic split of S2' },
+ { letter: 'E', color: '#059669', title: 'Erb\'s point', location: '3rd ICS, left sternal border', listen: 'Aortic regurgitation (best here), innocent flow murmurs' },
+ { letter: 'T', color: '#d97706', title: 'Tricuspid area', location: '4th–5th ICS, lower left sternal border', listen: 'Tricuspid regurgitation, VSD, S3/S4, holosystolic murmurs' },
+ { letter: 'M', color: '#7c3aed', title: 'Mitral area (apex)', location: '5th ICS, mid-clavicular line', listen: 'S1, mitral regurgitation, mitral stenosis (with bell, left-lateral decubitus)' }
+ ];
+
// ────────────────────────────────────────────────────────────
// RESPIRATORY SOUNDS LIBRARY
// ────────────────────────────────────────────────────────────
@@ -870,6 +959,77 @@
],
abnormalHints: ['Bronchophony increased — consolidation', 'Egophony positive ("ee" → "A" / "ay") — consolidation, sometimes top of an effusion', 'Whispered pectoriloquy positive (whisper clearly audible) — consolidation'] }
]
+ },
+ cv: {
+ overview: 'Systematic cardiovascular exam: inspection → palpation → auscultation at the five classic points → peripheral vascular exam. Always palpate the apex BEFORE auscultating — knowing where the apex lies tells you where to put the stethoscope and flags cardiomegaly immediately.',
+ components: [
+ { name: 'Inspection',
+ significance: 'Detects obvious precordial activity, chest-wall signs of congenital heart disease, and systemic markers (cyanosis, clubbing, dysmorphic features).',
+ pearl: 'Clubbing + central cyanosis in a well-appearing adolescent = cyanotic congenital heart disease until proven otherwise. Inspect the fingernails before reaching for the stethoscope.',
+ steps: [
+ { label: 'General appearance', method: 'Observe body habitus, features suggesting syndromic CHD (Turner, Down, Marfan, Williams).', normal: 'No dysmorphic features, appropriate growth' },
+ { label: 'Central cyanosis', method: 'Inspect lips, tongue, and oral mucosa for bluish discoloration.', normal: 'Pink oral mucosa, no cyanosis' },
+ { label: 'Peripheral cyanosis / clubbing', method: 'Inspect nail beds; do Schamroth\'s window (oppose nails of 4th fingers — normally forms a diamond-shaped window).', normal: 'Pink nail beds, Schamroth window present' },
+ { label: 'Precordial bulge', method: 'Inspect anterior chest wall tangentially for asymmetric prominence over the heart.', normal: 'Symmetric chest, no bulge' },
+ { label: 'Visible apex beat', method: 'Inspect for a visible cardiac impulse at the 5th ICS mid-clavicular line.', normal: 'Apex may be visible in thin patients; should not be displaced' },
+ { label: 'Neck veins (JVP)', method: 'Patient reclined 45°, head turned slightly left. Observe the right internal jugular pulsation; measure vertical height above the sternal angle.', normal: '≤ 4 cm above sternal angle (≤ 9 cm H₂O from right atrium)' }
+ ],
+ abnormalHints: ['Central cyanosis — right-to-left shunt, severe hypoxemia', 'Clubbing — cyanotic CHD, chronic hypoxemia', 'Precordial bulge — long-standing cardiomegaly (grew during skeletal growth)', 'Visible apex displaced lateral/inferior — cardiomegaly', 'Elevated JVP — right-heart failure, fluid overload, cardiac tamponade'] },
+
+ { name: 'Palpation',
+ significance: 'Localises the apex (confirms cardiac size), detects thrills (loud murmurs), and identifies a parasternal heave (RV hypertrophy).',
+ pearl: 'If you feel a thrill, the murmur is at least grade 4/6 — grade your murmur as ≥4 even if it sounds less impressive. Thrill = loud, palpable turbulence.',
+ steps: [
+ { label: 'Apex beat — localise', method: 'Feel with the tips of the fingers at the 5th ICS mid-clavicular line. If not found, roll the patient to the left lateral decubitus position.', normal: 'Located at 5th ICS, mid-clavicular line, less than 2 cm in diameter' },
+ { label: 'Apex character', method: 'Describe: tapping (normal), heaving (pressure overload, e.g. AS/HTN), thrusting (volume overload, e.g. AR/MR), dyskinetic (MI/aneurysm).', normal: 'Brief tapping quality' },
+ { label: 'Parasternal heave', method: 'Place the heel of the hand along the left sternal border. Sustained outward movement with each systole = heave.', normal: 'No heave' },
+ { label: 'Thrills', method: 'Use the palmar aspect of the hand at each of the 5 auscultation areas (A, P, E, T, M). A thrill = palpable turbulence.', normal: 'No thrills' },
+ { label: 'Peripheral pulses — upper', method: 'Palpate radial pulses bilaterally, then brachial. Note rate, rhythm, volume, and symmetry.', normal: 'Symmetric 2+ pulses, regular rhythm, age-appropriate rate' },
+ { label: 'Peripheral pulses — lower', method: 'Palpate femoral pulses. Compare to brachial — radio-femoral or brachio-femoral delay suggests coarctation of the aorta.', normal: 'Femoral pulses 2+ symmetric, no delay relative to radial' }
+ ],
+ abnormalHints: ['Apex displaced laterally/inferiorly — cardiomegaly', 'Heaving apex — pressure overload (AS, HTN)', 'Thrusting apex — volume overload (AR, MR)', 'Thrill over precordium — always pathological; at least grade 4/6 murmur', 'Parasternal heave — RV hypertrophy (pulmonary HTN, pulmonary stenosis, VSD with Eisenmenger)', 'Radio-femoral delay — coarctation of the aorta (always check in a hypertensive adolescent)'] },
+
+ { name: 'Auscultation — approach',
+ significance: 'Systematic technique ensures every relevant finding is detected. Listen at all 5 points, with both diaphragm and bell, in supine/sitting/left-lateral positions as needed.',
+ pearl: 'Time every murmur by simultaneously palpating the carotid pulse with the fingers of your free hand. Pulse = systole. Murmur heard during the pulse = systolic; in between pulses = diastolic.',
+ steps: [
+ { label: 'Positioning', method: 'Patient supine, head of bed at 30°. Exam room quiet, patient relaxed. Warm the stethoscope first.', normal: 'N/A — technique' },
+ { label: 'Diaphragm technique', method: 'Firm contact with skin. Detects HIGH-pitched sounds: S1, S2, systolic ejection murmurs, AR, MR.', normal: 'N/A — technique' },
+ { label: 'Bell technique', method: 'Very light contact — enough to make a seal but not stretch the skin. Detects LOW-pitched sounds: S3, S4, mitral stenosis rumble.', normal: 'N/A — technique' },
+ { label: 'Listen at each of the 5 points', method: 'A → P → E → T → M in order, each with diaphragm then bell. Spend a full cycle at each zone.', normal: 'S1 crisp, S2 clear (splits physiologically on inspiration at P), no added sounds, no murmur' },
+ { label: 'Left lateral decubitus position', method: 'If apex murmur suspected. Roll patient to left side. Listen at the apex with the BELL for mitral stenosis rumble or S3/S4.', normal: 'No added sounds, no diastolic rumble' },
+ { label: 'Sitting forward, held expiration', method: 'Patient leans forward, exhales fully, holds. Listen at left lower sternal border and Erb\'s point with the DIAPHRAGM for aortic regurgitation (soft early diastolic decrescendo).', normal: 'No early-diastolic murmur' }
+ ],
+ abnormalHints: ['Fixed split S2 (no change with respiration) — ASD', 'Loud S2 at pulmonic area — pulmonary HTN', 'S3 — volume overload, CHF (can be normal in young athletes)', 'S4 — stiff ventricle (HTN, HCM, ischemia)', 'Audible opening snap — mitral stenosis (rare in children)'] },
+
+ { name: 'Auscultation — heart sounds and murmurs',
+ significance: 'Characterising a murmur by timing, location, radiation, pitch, quality, and dynamic maneuvers narrows the differential.',
+ pearl: 'Innocent murmurs in children share 7 "S" features: Soft (≤ grade 2), Systolic, Short, Single (no added S3/S4), Small (localised, non-radiating), Sweet (musical), Sensitive to position/respiration (louder supine, softer standing). Anything breaking this pattern deserves workup.',
+ steps: [
+ { label: 'S1', method: 'Listen at the apex (mitral). Coincides with the carotid pulse upstroke. Mitral + tricuspid closure.', normal: 'Single, crisp, single-component sound' },
+ { label: 'S2', method: 'Listen at the pulmonic area in HELD INSPIRATION and HELD EXPIRATION. Note whether S2 splits physiologically (wider in inspiration, narrower/absent in expiration).', normal: 'Physiologic split (widens on inspiration, narrows on expiration)' },
+ { label: 'S3 / S4 gallops', method: 'Bell at the apex in left lateral decubitus. S3 = early diastole (after S2), low-pitched. S4 = late diastole (just before S1).', normal: 'Absent in adults; S3 can be normal in young athletes under age 30' },
+ { label: 'Identify murmur — timing', method: 'Time vs carotid pulse. Systolic (during pulse) vs diastolic (between pulses) vs continuous.', normal: 'No murmur, or only soft innocent flow murmur' },
+ { label: 'Identify murmur — location + radiation', method: 'Where loudest? Does it radiate? AS → carotids. MR → axilla. Coarctation → back.', normal: 'N/A — characterise only if murmur present' },
+ { label: 'Identify murmur — character', method: 'Crescendo-decrescendo (ejection) vs holosystolic (plateau) vs decrescendo early-diastolic (AR, PR) vs mid-diastolic rumble (MS, TS).', normal: 'N/A — characterise only if murmur present' },
+ { label: 'Grade intensity', method: 'Levine 1–6 scale (see scales card above).', normal: 'No murmur, or grade ≤ 2 soft innocent flow murmur' },
+ { label: 'Dynamic maneuvers', method: 'Standing: ↑HOCM, ↑MVP click (earlier). Squatting: opposite. Valsalva: ↑HOCM, most others decrease.', normal: 'No significant change with posture' }
+ ],
+ abnormalHints: ['Holosystolic murmur at apex → axilla — mitral regurgitation', 'Holosystolic at lower left sternal border (LLSB) — VSD, tricuspid regurgitation', 'Systolic ejection at upper right sternal border → carotids — aortic stenosis', 'Systolic ejection at upper left sternal border — pulmonary stenosis', 'Continuous "machinery" below left clavicle — PDA', 'Early diastolic at Erb\'s point, leaning forward — aortic regurgitation', 'Diastolic rumble at apex, bell in left-lateral — mitral stenosis', 'Fixed split S2 + systolic flow murmur — ASD'] },
+
+ { name: 'Peripheral vascular exam',
+ significance: 'Coarctation of the aorta hides until BP and pulses are checked in all four extremities. Differential diagnosis of a hypertensive adolescent should include this in the first 60 seconds.',
+ pearl: 'Four-limb BP measurement is mandatory in any adolescent with hypertension or a murmur. Upper-extremity BP > lower-extremity BP (or brachio-femoral delay) = coarctation until excluded.',
+ steps: [
+ { label: 'Four-limb blood pressure', method: 'Measure BP in right arm, left arm, and at least one leg. Use appropriately sized cuff (bladder width 40% of limb circumference, length 80–100%).', normal: 'Arm BPs within 10 mmHg of each other; leg systolic within 20 mmHg of arm systolic (may be higher)' },
+ { label: 'Radial pulses', method: 'Palpate both radials simultaneously — note any delay or asymmetry.', normal: 'Simultaneous, symmetric, 2+' },
+ { label: 'Radio-femoral delay', method: 'Palpate radial and femoral simultaneously. Feel the femoral as clearly "after" the radial = delay.', normal: 'No delay' },
+ { label: 'Femoral pulses', method: 'Palpate both femoral pulses at the mid-inguinal point. Compare amplitude to radials.', normal: 'Symmetric 2+ pulses, equal amplitude to radial' },
+ { label: 'Dorsalis pedis + posterior tibialis', method: 'Palpate in both feet.', normal: '2+ pulses bilaterally' },
+ { label: 'Capillary refill', method: 'Press and release the nail bed; time to normal colour.', normal: '< 2 sec' }
+ ],
+ abnormalHints: ['Asymmetric upper-extremity BP (> 10 mmHg) — subclavian stenosis or coarctation at the origin', 'Upper >> lower-extremity BP — coarctation of the aorta', 'Diminished or absent femoral pulses with brachio-femoral delay — coarctation', 'Bounding pulses with wide pulse pressure — AR, PDA, arteriovenous fistula, thyrotoxicosis, anemia', 'Weak thready pulses — low output state (heart failure, shock, hypovolemia)', 'Prolonged capillary refill — dehydration, shock, cold stress'] }
+ ]
}
}
};
@@ -931,10 +1091,10 @@
return;
}
var section = group[currentSystem];
- var accentMap = { msk: '#0891b2', neuro: '#7c3aed', resp: '#0ea5e9' }; // cyan / purple / sky
- var accentTintMap = { msk: '#ecfeff', neuro: '#f5f3ff', resp: '#f0f9ff' };
- var iconMap = { msk: 'bone', neuro: 'brain', resp: 'lungs' };
- var labelMap = { msk: 'Musculoskeletal', neuro: 'Neurologic', resp: 'Respiratory' };
+ var accentMap = { msk: '#0891b2', neuro: '#7c3aed', resp: '#0ea5e9', cv: '#e11d48' }; // cyan / purple / sky / rose
+ var accentTintMap = { msk: '#ecfeff', neuro: '#f5f3ff', resp: '#f0f9ff', cv: '#fff1f2' };
+ var iconMap = { msk: 'bone', neuro: 'brain', resp: 'lungs', cv: 'heart-pulse' };
+ var labelMap = { msk: 'Musculoskeletal', neuro: 'Neurologic', resp: 'Respiratory', cv: 'Cardiovascular' };
var accent = accentMap[currentSystem] || '#0891b2';
var accentTint = accentTintMap[currentSystem] || '#ecfeff';
var icon = iconMap[currentSystem] || 'circle-info';
@@ -947,6 +1107,28 @@
html += '
' + esc(section.overview) + '
';
html += '